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UGS REV 2

ABN: 69 410 335 356

Application for an Underground Supervisor’sCertificate of Competency

I hereby apply for an Underground Supervisor’s Certificate of Competency under the Mines Safety and Inspection Act 1994 and Mines Safety and Inspection Regulations 1995, and submit the following documentation and information.

1. Applicant details (please print)

Family name Given names

Date of birth / / Email

Phone (day) Facsimile Mobile

Postal address

Unit no. Street no. Lot no. Street name

PO Box no. Town/suburb State Postcode

2. Examination venue (please tick preferred venue of examination)

Perth Kalgoorlie Karratha Collie Have you previously sat this exam? Yes No

3. Statutory declaration

I (name in full)

of (address)

declare that the foregoing particulars are true and correct in every detail and I make this solemn declaration under the Oaths, Affidavits and Statutory Declarations Act 2005. (For information on who can witness statutory declarations, refer to the Department of the Attorney General’s website at www.courts.dotag.wa.gov.au/w/witnessing_documents.aspx)

Declared at in the state or territory of

Date / /

Signature of declarant

Before me (signature of witness)

Name of witness

Address of witness Postcode

Title or qualification of witness

RSD

Feb1

3_77

4

100 Plain Street, East Perth WA 6004 Telephone: 08 9358 8014 Fax: 08 9358 8000 www.dmp.wa.gov.au

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UGS REV 2

4. Payment details

Cheques and money orders should be made payable to: Department of Mines and Petroleum ..................................................................................................................................................................................................................

Application for a Certificate of Competency

Complete this section if paying by credit card

Card number Expiry date /

Card type (please tick) Mastercard Visa

Cardholder’s name

Amount Signature

Phone number of card holder Date / /

5. Checklist (please tick the boxes to ensure your submission is complete)

The Mines Safety and Inspection Regulations 1995 [r. 2.23] requires the applicant to submit the following documentation.

Evidence of attaining minimum age of 23 years (e.g. birth certificate, passport or driver’s licence)

(Graduates only) Certified copy of appropriate degree with the academic transcript (if the degree is from a non-Australian or New Zealand institution also attached letter of assessment from the Overseas Qualification Unit)*

Character reference

Current first aid certificate

Application fee

Evidence of five years experience (graduates two years) on a mine site, which must include**

– six months experience directly involved in ground support, haulage and transport and in general mine servicing

– three months face experience in operating a rockdrill on development and stoping face (a minimum 65 shifts must be completed)

– three months personal experience in using explosives in charging and firing both development and stoping rounds (a minimum 65 shifts must be completed)

* the overseas qualification unit is part of the Department of Training and Workforce Development. Phone: 13 23 98 or visit www.trainingwa.wa.gov.au

** letters of experience must be provided and signed off by a responsible officer of the company in which experience has been gained using company letterhead. It should include precise details of the types of duties and dates associated with each. Drilling and blasting time must include number of shifts if experience is less than five months.

Experience records in the form of Statutory Declaration may be acceptable only in the original experience document from a mine cannot be obtained. Inquiries, if conducted, to establish accuracy of experience given in the form of a Statutory Declaration may cause delays in the finalisation of a decision on your application.

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UGS REV 2

Chairman

Member

Member

Member

Member

Member

Approval for an Underground Supervisor’s Certificate of Competency

Date / /

Application lodgementComplete the application section, including the checklist and attach all the required information and the fee payable to the Department of Mines and Petroleum, is to be mailed to:

Board of Examiners Resources Safety Department of Mines and Petroleum 100 Plain Street East Perth WA 6004.

or handed in person at:

Board of Examiners Resources Safety Level 1, 303 Sevenoaks Street (Cnr Grose Avenue) Cannington WA 6107.

Office hours: 8:30 am to 4:30 pm

Contact details

Tel: (08) 9358 8014Fax: (08) 9358 8000Email: boe@dmp.wa.gov.auWebsite: www.dmp.wa.gov.au/ResourcesSafety for fees,

forms, past exam papers and exam dates.

Board’s decision (office use only)